Doctors differ over ACL repair techniques

Hummel's two operations were different

Jan. 16, 2011

Dr. Robert Hagen examines Shannon Littlewood's left knee on Dec. 22 as a follow-up to recent ACL surgery, at Lafayette Orthopaedic Clinic. Littlewood, a freshman at Harrison High School, tore her ACL during a soccer game last September. / By John Terhune/Journal & Courier

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About this series

On Sunday we launched an exploration of the causes, consequences and costs of ACL injuries, which are sending up to 200,000 Americans to the operating table annually.

Sunday and today the focus is on Purdue University athletes. Future installments will delve into treatment options, the latest surgical techniques and what athletes and nonathletes can do to reduce risk of injury.

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If you have had an ACL experience and would like to share your story, contact projects editor David Smith at dsmith@jconline.com, or drop him a line at Journal & Courier, 217 N. Sixth St., Lafayette, 47901.

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In a medical career that spans more than three decades, Dr. Donald Shelbourne of Indianapolis has surgically reconstructed thousands of ACLs or anterior cruciate ligaments.

Shelbourne believes modern athletics are taking a toll on ACLs. Single-sport athletes typically spend less time in practice and more time in grueling game situations, he said. Meanwhile, strength conditioning is making leg muscles bigger and stronger but not the knee ligaments themselves.

The ACL, located behind the knee cap, is one of several ligaments connecting the thighbone and shinbone but the one most frequently injured.

"The medical field can't reduce the number of ACL injuries," said Shelbourne, who's treated Purdue athletes for 28 years. "We're kind of stuck."

While the medical field can't reduce ACL injuries, it has developed new ways of treating them. The case of Purdue's Robbie Hummel, who has had two ACL reconstructions in the past 10 months, presents a contrast of surgical techniques.

Shelbourne performed the first surgery last March after Hummel tore his ACL in a game on Feb. 24.

The second surgery on Nov. 16 became necessary after Hummel's reconstructed ACL tore on the second day of basketball practice in October.

Dr. Robert Hagen, a Lafayette orthopedic surgeon, said he is an adherent of using arthroscopic surgery to reconstruct ACLs.

In arthroscopic surgery, a small incision is made through which a fiber optic camera is inserted, projecting a magnified image of the knee on a TV monitor. Guided by the image, the surgeon guides other instruments through similar incisions to remove the old ACL and implant a replacement or graft.

Shelbourne uses an arthroscope to inspect and partially repair the damaged knee, but the actual ACL reconstruction is done via open incision. This type of surgery leaves 3- to 4-inch scars and, Hagen believes, lacks the precision of arthroscopic surgery.

"Purdue is a technology school -- great in technology -- and Hummel had the least technologically advanced ACL (surgery) you can have," Hagen said of the first surgery.

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Shelbourne, however, defends his techniques and points out that not every ACL surgery is a sure take the first time around.

Estimates vary, but at least 4 percent of patients who have had ACL reconstruction end up having ACL surgery again on the same knee, according to a 2009 article in the American Journal of Sports Medicine. Subsequent reconstructions of the same ACL are called revisions.

Shelbourne has performed 479 revision surgeries on athletes who have torn the same ACL twice and 17 on patients who had torn their ACL a third time.

Hummel's experience, however, was the first time one of his ACL surgeries on a Purdue athlete failed when put to the test, he said.

"It was the worst day of my life," Shelbourne said. "In 28 years of working with Purdue athletes, it never happened to me. For it to happen to Rob, it was awful."

Different approach

Dr. David Altcheck, a New York-based orthopedic surgeon, did the second ACL on Hummel at his parents' request.

Altcheck said he has utmost respect for Shelbourne, whom he considers a close colleague.

However, he agrees with Hagen that arthroscopic surgery is the way to go.

Choice of graft

ACL reconstruction surgery consists of harvesting a piece of tendon or ligament from elsewhere in the body or from a cadaver, then surgically implanting it in place of the damaged ACL.Another point of departure between Hummel's first and second surgeries was the source of the replacement tissue. Both used sections taken from the patellar tendon, connecting the knee cap to the shinbone, to replace the torn ACL.

In Hummel's first surgery, Shelbourne obtained the graft tissue from the player's uninjured knee, a technique called a contralateral graft. This practice is designed to minimize trauma to the damaged knee and aid in recovery.

It's a technique neither Hagen nor Altcheck favor.

"It has kind of been found that it doesn't change or help the overall result," Hagen said. "In fact, what you're doing is giving someone two sore knees instead of one. Some patients complain more about the knee from which you took the ACL (graft). Plus, it's two scars and two potential sites of infection."

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Altcheck, who does about 200 ACLs a year, said he has used contralateral reconstructions in the past but now only uses it when the situation warrants, such as when the patellar tendon in the ACL-damaged knee is damaged as well.

"I certainly respect Dr. Shelbourne," Altcheck said. "He is a close colleague of mine and really has been a proponent of the contralateral technique, which has worked really well for him.

"Obviously, you're doing less trauma to the ACL knee, but you are doing some trauma to the other knee. I just didn't find that it was a big advantage," Altcheck said.

'It feels solid'

Hagen and other arthroscopic surgeons prefer to use screws to anchor the replacement tissue inside the thighbone and shinbone. Shelbourne's procedure relies on buttons on the surface of the bones to which the ends of the graft are tied.

Hagen, who performs about 100 ACL surgeries each year, said that when he operates on an athlete, the bone usually is of such good quality that when he inserts a screw, he can hear it squeak.

"It's like putting a screw into a nice piece of wood," Hagen said. "It feels solid when you are done. Then, you don't have to worry about slipping or falling or twisting the knee in some way and tearing those stitches out or breaking the button or disrupting the ligament that is in there."

Dr. Robert H. Brophy, assistant professor of orthopedic surgery at Washington University of St. Louis, said he knows of no study that shows arthroscopic ACL surgery is better than open-incision or visa versa.

"Some people still do (open incision) and have very good results," he said. "The vast majority do arthroscopy."

In either method, once ACL reconstructive surgery is complete, a carefully guided rehabilitation regime is paramount.

"That part of it has gotten great," Hagen said. "Our surgery techniques are pretty good, but the therapy has gotten so much better. They start with them the day they get injured."